Implant and method for repair of the anterior cruciate ligament

ABSTRACT

Described herein are methods and devices for use in repair of a patient&#39;s anterior cruciate ligament (ACL). These methods (and devices for performing them) allow the repair, rather than merely replacement, of the ACL. For example, described herein are anchoring devices that may be inserted into a bone and may anchor a scaffolding/support (e.g., graft) material within the bone so that the torn or damaged end of the ACL may be secured to the scaffolding/support material within the femoral notch. These anchoring devices and method of using them are particularly well suited for use with the continuous suture passers described herein, since these suture passers may allow access to previously inaccessible regions of the knee (or other body regions).

CROSS REFERENCE TO RELATED APPLICATIONS

This patent application claims priority to U.S. Provisional Patent Application No. 61/431,293, filed on Jan. 10, 2011, and titled “IMPLANT AND METHOD FOR REPAIR OF THE ANTERIOR CRUCIATE LIGAMENT.”

INCORPORATION BY REFERENCE

All publications and patent applications mentioned in this specification are herein incorporated by reference in their entirety to the same extent as if each individual publication or patent application was specifically and individually indicated to be incorporated by reference.

In particular, the following patent applications are herein incorporated by reference in their entirety: U.S. patent application Ser. No. 11/773,388, filed Jul. 3, 2007, titled “METHODS AND DEVICES FOR CONTINUOUS SUTURE PASSING”, Publication No. US-2009-0012538-A1; U.S. patent application Ser. No. 12/291,159, filed Nov. 5, 2008, titled “SUTURE PASSING INSTRUMENT AND METHOD”, Publication No. US-2010-0331863-A2; U.S. patent application Ser. No. 12/620,029, filed Nov. 17, 2009, titled “METHODS OF SUTURING AND REPAIRING TISSUE USING A CONTINUOUS SUTURE PASSER DEVICE”, Publication No. US-2010-0130990-A1; and U.S. patent application Ser. No. 12/942,803, filed Nov. 9, 2010, titled “DEVICES, SYSTEMS AND METHODS FOR MENISCUS REPAIR”, Publication No. US-2011-0112556-A1.

FIELD

This invention relates to devices, systems and methods for repair of the anterior cruciate ligament (ACL).

BACKGROUND

Tears to the anterior cruciate ligament (ACL) are painful and often debilitating. Surgery for ACL injuries typically involves reconstructing the ACL using a graft material to replace the torn ACL. For example, ACL reconstruction surgery typically uses a graft to replace or support the torn ligament. The most common grafts are autografts from the patient (e.g., from a tendon of the kneecap or one of the hamstring tendons), though donor allograft tissue may also be used, as well as synthetic graft material. Although ACL reconstruction surgery is often referred to as ACL “repair” surgery, the current standard of care for ACL tears is to replace the torn ligament with a graft, rather than attempting to sew the torn ACL together. Merely sewing together the torn ACL has proven ineffective.

In general, ACL surgery may be performed by making small incisions in the knee and inserting instruments for surgery through these incisions (arthroscopic surgery) or by cutting a large incision in the knee (open surgery). During arthroscopic ACL reconstruction, the surgeon may make several small incisions around the knee. Sterile saline solution is pumped into the knee through one incision to expand it and to wash blood from the area. This allows the doctor to see the knee structures more clearly. The surgeon then inserts an arthroscope into one of the other incisions with a camera at the end of the arthroscope that transmits images of the internal region. Surgical drills may be inserted through other small incisions to drill small holes into the upper and lower leg bones where these bones come close together at the knee joint. The holes form tunnels through which the graft will be anchored. The surgeon may take an autograft at this point. The graft may also be taken from a deceased donor (allograft). The graft may then be pulled through the two tunnels that were drilled in the upper and lower leg bones. The surgeon may secure the graft with screws or staples and close the incisions with stitches or tape.

Unfortunately, replacing the ACL with a graft material, which requires anchoring both ends of the graft material to bone, has proven technically difficult, resulting in a long surgical time, and may ultimately require a long recovery time. Replacement of native ACL material with graft material typically leads to the loss of native ACL proprioceptive fibers, and results in an alteration of the native ACL tibial footprint geometry. In some cases, removing autograft material from the patient may result in donor site morbidity, while donor allograft material presents an increase risk of HIV and Hepatitis C transmission.

Thus, it would be desirable to provide devices, systems and methods for repair of the ACL that do not require the replacement of the ACL and the formation of multiple anchoring sites. The systems, devices and methods for repair of the ACL described herein may address these concerns.

SUMMARY OF THE DISCLOSURE

The present invention relates to systems, devices and methods for repair of ACL using an anchor for use with a graft material that may be sutured directly onto the torn ACL. In particular the systems and methods described herein may use a continuous suture passer such as those described in many of the applications previously incorporated by reference in their entirety, including at least: U.S. patent application Ser. No. 11/773,388, filed Jul. 3, 2007, titled “METHODS AND DEVICES FOR CONTINUOUS SUTURE PASSING”, Publication No. US-2009-0012538-A1; U.S. patent application Ser. No. 12/291,159, filed Nov. 5, 2008, titled “SUTURE PASSING INSTRUMENT AND METHOD”, US-2010-0331863-A2; U.S. patent application Ser. No. 12/620,029, filed Nov. 17, 2009, titled “METHODS OF SUTURING AND REPAIRING TISSUE USING A CONTINUOUS SUTURE PASSER DEVICE”, US-2010-0130990-A1; and U.S. patent application Ser. No. 12/942,803, filed Nov. 9, 2010, titled “DEVICES, SYSTEMS AND METHODS FOR MENISCUS REPAIR”, Publication No. US-2011-0112556-A1.

For example, described herein are methods for repairing a torn ACL within the femoral notch. In some variations, the methods include the steps of: anchoring a graft within the femoral notch; and suturing a torn end of the ACL to the graft within the femoral notch. In general, the step of anchoring the torn end of the ACL to the graft is performed percutaneously. The graft may be integral to (or preattached to) an anchor such as a knotless anchor. In some variations the torn end of the ACL is twice anchored within the femoral arch: both to a suture passed through and/or around the torn end of the ACL, and then to a graft that is anchored within the ACL. The connection to the graft may be made second, so that it may reinforce the suture which can be secured within the ACL to the same (or in some variations a different) bone anchor.

For example, in some variations, the step of anchoring a graft comprises securing an anchor to which a graft has been coupled within the femur so that a proximal end of the graft extends from the femur. For example, anchoring a graft may comprise driving a guidewire through the femur and drilling an opening to hold a graft anchor; and securing an anchor coupled to a graft within the opening over the guidewire.

The anchor may be secured by screwing the anchor into the opening (e.g., the tunnel drilled through a region of the femoral notch).

In some variations, the method includes securing the torn end of the ACL to a suture and pulling the suture through the femur to position the torn end of the ACL adjacent to the graft. The step of suturing the torn end of the ACL may comprise passing a suture through the graft and the ACL multiple times, e.g., with a suture passer that is adapted for use within the narrow confines of the tissue. For example, the step of suturing the torn end of the ACL may comprise passing a suture through the graft and the ACL multiple times with a continuous suture passer without removing the suture passer from the tissue.

In some variations the method further comprises securing the torn end of the ACL to a suture and pulling the suture through the femur to anatomically tension the ACL adjacent to the graft.

Also described herein are methods for repairing a torn ACL within the femoral notch, the method comprising: anchoring a graft within the femoral notch; positioning a torn end of the ACL adjacent to the graft; and percutaneously suturing the torn end of the ACL to the graft within the femoral notch.

In some variations, the step of positioning comprises securing a suture to the torn end of the ACL. For example, pulling the suture through a tunnel in the femoral notch to position the torn end of the ACL adjacent to the graft. In some variations, the method includes the step of anchoring the torn end of the ACL to the femoral notch with a suture before percutaneously suturing the torn end of the ACL to the graft.

In any of the variations of methods described herein, the method may include forming (e.g., drilling) a tunnel through the femoral arch for anchoring the torn ACL. The step of anchoring the graft within the femoral notch may include anchoring the graft within a tunnel drilled through the femoral arch.

Also described herein are methods for repairing a torn ACL within the femoral notch, the method comprising: drilling a tunnel through a portion of the femoral notch; anchoring a graft within the tunnel through the femoral notch, wherein the graft extends from the tunnel; pulling a suture connected to a torn end of the ACL through the tunnel through the femoral arch to positioning the torn end of the ACL adjacent to the graft; anchoring the suture connected to the torn end of the ACL; and percutaneously suturing the torn end of the ACL to the graft within the femoral notch.

BRIEF DESCRIPTION OF THE DRAWINGS

FIGS. 1A and 1B show one variation of a knotless ACL repair screw (anchor) as described herein.

FIGS. 2A-2D illustrate one method of loading a suture into a knotless ACL repair screw such as the variation shown in FIGS. 1A-1B.

FIGS. 3A-3P illustrate one method of repairing an ACL using a knotless ACL repair screw.

FIGS. 4A-4D illustrate one method of securing an ACL (e.g., a torn ACL) to a suture as described herein.

FIG. 5 shows another variation of a knotless ACL repair screw.

FIG. 6 shows another variation of a knotless ACL repair screw.

FIGS. 7A and 7B show another variation of a knotless ACL repair anchor.

FIGS. 8A and 8B illustrate two variations of lead wires configured to extend from a suture shuttle for use with a continuous suture passer as described herein.

FIGS. 9A and 9B illustrate arthroscopic spatulas that may be used for knot typing and instrument insertion during any of the methods described herein.

DETAILED DESCRIPTION

In general, described herein are methods and devices for use in repair of a patient's anterior cruciate ligament (ACL). These methods (and devices for performing them) allow the repair, rather than merely replacement, of the ACL. It should be understood, however that the devices and systems described herein may also be used to replace an ACL. The anchoring devices described herein may be inserted into a bone and may hold a graft material within the bone so that the graft may also be attached to the torn or damaged ACL. The implanted anchoring device (which may also be referred to as an “implant” or “knotless graft anchor”) may be particularly well suited for use with any of the continuous suture passers described herein, since these suture passers may allow access to previously inaccessible regions of the knee (or other body regions). For example, the methods described herein may include access into the notch region (e.g., the femoral notch) to anchor a graft in an optimal position, and to suture the graft to the damaged ACL while maintaining as much of the native ACL as possible. Previous methods of “repairing” (rather than replacing) the ACL have proven unsuccessful at least in part because this region was difficult or impossible to successfully access. Suturing in the notch region, without the benefit of the continuous suture passers described and incorporated by reference herein, has proven extremely difficult and time consuming, discouraging such surgical repairs.

Any appropriate graft material may be used with the systems, devices and methods described herein. For example, an ACL graft for use with the methods and devices described herein may include: synthetic grafts (e.g., Gore-Tex, Dacron, carbon fibers, and polypropylene braids, etc.), biologic (e.g., porcine, human or other) allografts, autografts, etc. The graft materials describe herein may provide support or scaffolding for repair of the torn ACL, since the ACL is left in place and sutured to the graft. Thus, in some variations the graft may be a sleeve or patch (e.g., a graft jacket, Restore patch, etc.) The graft may include a biologic material such as a growth-promoting material that may promote in-growth, visualization, or the like (e.g., growth factors, etc.).

In general, the devices described herein include a knotless ACL graft anchor, which may also be referred to as an ACL graft anchor, a one-way ACL graft anchor, a knotless ACL repair screw, or merely a “device”. These ACL graft anchors may include a one-way path for passing (and therefore anchoring) a suture, as well as a coupling region for coupling to a graft material. The one-way path may be a central passage through the device. In general the one-way path forms a channel through the device and may include cams or other locking members that prevent a suture passing through the one-way path from pulling out the device. The one-way path may be referred to as the suture channel or path, since the suture may extend through (and be held within) the one-way path, although other elements (e.g., a guidewire, such as a beath pin, etc.) may also be passed through the channel. The one-way channel may extend from the proximal to the distal ends of the device, which may advantageously allow the ACL graft anchor to be easily implanted and positioned, and may anchor the suture (e.g., connected to an ACL) at or within a bone region of the femoral notch. For example, the suture may be drawn through the implant to pull the distal end portion of a torn ACL towards (and to or into) the proximal end of the ACL graft anchor. The anterior end of the implant is typically the end that is not completely inserted into the bone, or that faces away from the bone.

As mentioned above, the anchors described herein allow both securing (e.g., suturing) of the torn ACL to the scaffold/support (e.g., graft) after the graft has been anchored into the bone, but also tensioning of the torn ACL by pulling and locking the position of a suture that has been secured to the torn end of the ACL. In particular, the anchor includes a one-way pathway that allows the suture connected to the torn end of the ACL to be pulled and held (locked) distally, to adjust the tension on the ACL as it is being positioned adjacent to the graft so that it can then be sutured to the graft. The one-way locking mechanism in the suture pathway through the anchor allows this tensioning. Thereafter, the reinforcing support of the graft (scaffolding) maintains the tension and position of the ACL for short-term repair and long-term healing. Thus, described herein are anchor devices that are configured to both pre-tension a torn ACL and to secure the tensioned ACL to the reinforcement graft anchored in the bone by the device. In general, these devices therefore include a one-way (locking) path for a suture to be drawn through the body of the anchor as well as a coupling region for a graft, or a graft that is already integrally part of the device.

The coupling region that may couple to a graft may be located as the distal end (e.g., the end to be inserted into the bone) of the device so that the graft will be anchored at one end in the bone. The coupling region may be positionable or rotatable around the circumference of the device. In some variations the coupling region is a loop or ring that is rotatably attached around the distal end region of the ACL anchor, which is also connected to a second loop or ring through which the graft (e.g., ACL graft) may pass and be secured. A coupling region may be referred to as a collar. Alternatively, the attachment region may include a suturing substrate (e.g. fabric) to which the graft may be coupled or connected. In some variations, the coupling region may include a passage through the device through which the graft may be passed. In some variations the coupling region is connected (or formed of) the distal end of the ACL anchor, which may be rotatable around the long axis of the ACL graft anchor.

Thus, in general, the ACL anchors described herein are configured to secure both an ACL graft (which is to be sutured to the ACL) and a suture that is also connected to the torn ACL.

The ACL anchors described herein may also be configured to secure within an opening drilled into the bone. For example, the sides may be self-tamping, ridged, expandable, or the like, to secure the anchor within the bone. The body of the anchor may also include one or more passages or opening into which bone may grow (or be encouraged to grow). In some variations the device includes lateral openings into which a cross-pin or other additional anchoring device may be inserted.

For example, FIGS. 1A and 1B show one variation of a knotless ACL repair screw. In this example the ACL graft anchor has a screw-shape body (e.g., a threaded body) that extend in a proximal-distal longitudinal direction. The distal end includes a distal collar for attachment to a graft material; the distal collar (coupling region) includes a loop through which the graft material may pass and be secured, and a collar region surrounding an opening at the distal end. Thus, the collar can rotate relative to the body of the device. This allows the threaded, screw-shaped body to be screwed (rotated) into position within the bone, while the graft at the distal end may remain in the same position (e.g., on one side of the body). In FIG. 1A, the distal collar can rotate freely with respect to the screw (body of the anchor), and has an eyelet through which any reinforcement graft or allograft can be inserted (e.g., a graft jacket, Restore Patch, tibialis anterior allograft, etc.).

The ACL repair screw (anchor) body in FIG. 1A may be made out of PEEK material. In this example, the outer body region is threaded for screwing into a channel made in the bone. The device includes a central channel that creates a one-way passage for a suture, and can thereby anchor a suture in position. For example, the central channel may include tabs that create a one-way pathway for a suture. In other variation the suture is allowed to pass only in one direction (e.g., towards the distal end of the implant) by tabs, clamps, cams, ball valves, check valves, or the like).

FIG. 1B shows the device of FIG. 1A with exemplary range of dimensions (e.g., length of approximately 15-20 mm, and width of approximately 3-8 mm). In some variations, a smaller diameter screw may be beneficial because a smaller diameter screw will allow more contact of the ligament to bone at the repair site.

FIGS. 5 to 7B also illustrate alternative variations of anchors that may be used with the systems and methods described herein. For example, in FIG. 5, the anchor includes a central one-way path for a suture that is locked in place by a ball valve. In FIG. 6, the anchor does not include a passageway completely through the anchor, but instead has a passageway that passes both in and out of the anchor at the proximal end. The passageway may also be valved to allow only one-way travel through the device, as shown. In both FIG. 5 and FIG. 6, the embodiments shown include a suture forming a loop at the distal end, which may be connected to an ACL so that the ACL may be drawn towards and anchored into position relative to the anchor. FIGS. 4A to 4D, described in greater detail below, illustrate securing the end of an ACL to a suture so that it can be loaded into a knotless anchor.

FIGS. 7A and 7B illustrate another variation of an ACL anchor in which the anchor secured itself into position within a hole or opening in the bone. This design may allow for a smaller hole to be made in the bone (e.g., the bone forming the notch region). In this example, as shown in FIG. 7A, the implant (with a one-way passage) is inserted into a passage in the bone as shown. In this example, the scaffold material (e.g., graft) is not shown, but is included. Once in position, the anchor may be locked in place by expanding at least a region of the implant. For example, in FIG. 7B, the proximal end of the device expands outwards against the walls of the opening or passage in the bone, locking it in place, as shown. A suture (not shown) may be pulled through the one-way passage in the anchor, to draw the ACL towards the device, and potentially into the bone. The ACL may then be secured in position and so that in-growth can help anchor it in place. In some variations, the anchor includes a cam or camming mechanism that may create a one-way anchor within the channel for the suture.

As mentioned above, any appropriate suture passer may be used, particularly those described in: U.S. patent application Ser. No. 11/773,388, filed Jul. 3, 2007, titled “METHODS AND DEVICES FOR CONTINUOUS SUTURE PASSING”, Publication No. US-2009-0012538-A1; U.S. patent application Ser. No. 12/291,159, filed Nov. 5, 2008, titled “SUTURE PASSING INSTRUMENT AND METHOD”, Publication No. US-2010-0331863-A2; U.S. patent application Ser. No. 12/620,029, filed Nov. 17, 2009, titled “METHODS OF SUTURING AND REPAIRING TISSUE USING A CONTINUOUS SUTURE PASSER DEVICE”, Publication No. US-2010-0130990-A1. For example, suture passers having a suture shuttle that is configured to clamp to the side of a curved tissue penetrator that can be extended and retracted to pass the suture shuttle (and any attached suture) back and forth between two open/closed jaws or arms are of particular interest. In this example, the suture shuttle may generally include a shuttle body that clamps to the tissue penetrator, and has an extension region (“leash”) with a suture attachment region at the end. In this way the suture may be held slightly apart from the tissue penetrator, and not interact directly with the tissue penetrator.

In some variations, the shuttle used for passing the suture by a continuous suture passer may be further adapted for use with the devices and methods described herein. For example, the shuttle may be configured to include a lead wire that allows a region of one or more loop to be cut free after the initial ACL suture is placed (because the central part of the suture may be passed to allow a loop to be formed, through which the proximal aspect of the suture ends can be inserted for a self-cinching pattern. See, for example, FIGS. 4A-4D. FIGS. 8A and 8B illustrate variations of suture shuttles including multiple (two in this example) loops extending from the body of the suture shuttle. The outer loop may be cut away, broken or otherwise opened to release a suture or loop of suture. The same suture shuttle may the then be used again without having to remove it from the tissue, and without having to draw one or both free ends of the suture out of the loop.

In any of the variations described herein, one or more arthroscopic devices may be used to help manipulate the tissue, in addition to the suture passers (or in place of the suture passers) described. For example, FIGS. 9A and 9B illustrate two variations of arthroscopic spatulas that may be used for knot typing and instrument insertion, as appropriate.

In general, any of the anchors described herein may be used as part of a system for repairing ACL. Such a system may also include a continuous suture passer and or suture material. In particular, continuous suture passers that are capable of passing a suture back and forth (e.g., by connection to a shuttle member) between two arms or jaws while the jaws are open around the tissue (e.g., ACL tissue), are of particular interest. Thus, the system may include the suture passer, one or more suture shuttles and one or more anchors as described herein. For example, the shuttles described may include those illustrated in FIG. 8A or 8B. In some variations, the systems also include a tool or tools for forming a hole or opening in bone of the notch into which the anchor may be positioned, and a guidewire, needle or pin for inserting the device and/or for threading a suture through the anchor. Additional manipulation tools, including those shown in FIGS. 9A and 9B, may also be included.

Methods of Repairing ACL

Also described herein are methods of repairing a torn ACL. These methods may generally include anchoring one end of a scaffold in the femoral notch, for example, by securing an anchor that holds one end of a flexible scaffold for attaching to the patient's ACL. The scaffold may be a graft, sleeve, patch, or the like. The anchoring may include anchoring a scaffold (e.g., graft) using an ACL graft anchor such as those described above. The scaffold may be secured by first driving a pin (e.g., beath pin) though the posterolateral femoral arch), drilling an opening into which the ACL graft anchor may sit. In some variations a second tunnel or passage for the graft, adjacent to the first, may also be formed. An ACL graft anchor with an attached ACL scaffold may then be secured into the opening formed through the femoral arch bone. In some variations a guidewire may be used to guide both the drill and/or the ACL graft anchor so that it can be positioned. Once the scaffold (e.g., graft) is anchored in the femoral arch, the torn end of the ACL, in variation in which the ACL has torn away, may be pulled towards the ACL anchor and scaffold and sutured to the scaffold while in the notch. For example, the end of the torn ACL may be sutured or connected to a suture and the suture drawn though the body of the suture anchor to pull the end of the ACL towards the anchor and the graft. The suture may hold the ACL in position so that it may be sutured (using a separate suture) to the graft material, thereby re-attaching the ACL to the femoral arch region. In some variations the end of the suture is passed through the anchor distally, along the one-way passage through the anchor, holding it in position.

For example, FIGS. 2A-2D illustrate one variation of a method for anchoring a scaffolding (e.g., an ACL graft) and also a method for positioning a torn ACL next to the anchor and graft so that it can be sutured to the graft. FIGS. 3A-3P show an example of a method for repairing an ACL, including steps for anchoring the scaffolding/support in the femoral notch and suturing the ACL to the scaffolding support while the end of the ACL is in the femoral notch.

In FIG. 2A, the anchor, which in this embodiment is shown similar to the variation of FIGS. 1A and 1B as an ACL screw anchor, may be threaded over a guide wire. Any appropriate guidewire may be used, for example, a beath pin type of guidewire that is known to be used in ACL reconstruction. The guidewire is threaded through the central (one-way suture passage) of the anchor, and in this variation the guidewire may disable the one-way cams/tabs within the channel that prevent the suture from being pulled proximally when a suture is passed through the channel. For example, the one-way tabs may fold to allow passage over the pin/guidewire. As shown in FIGS. 3A-3P, the guidewire or pin may be used to place or position the anchor into a hole formed in the femoral notch, to place and thereby anchor the ACL graft.

In FIG. 2B, sutures are loaded into the beath pin eyelet and the beath pin (guidewire) is pulled distally through the screw to load the sutures into the anchor, as shown. In this example, the anchor may already be positioned within the notch (not shown), and the sutures may already be secured to the end of the ACL. For example, in FIG. 2C, the sutures are loaded into the anchor, and pulling on the sutures to the left (through the anchor) pulls the ACL tissue toward the anchor base (the proximal end of the anchor) through the suture channel in the anchor, in a one-way, self tightening fashion. In this example, the suture channel includes cams or tabs that allow the suture to be pulled distally but not proximally, as indicated by the arrow. Eventually, as shown in FIG. 2D, the ACL to which the suture is attached will be pulled adjacent to the proximal end of the anchor (not drawn to scale, as the ACL will typically be much larger than the anchor). In some variations, the ACL may be pulled at least partially into the channel formed in the bone into which the anchor is placed. Once the ACL is pulled (via the suture) adjacent to the anchored scaffolding or graft, it may be sutured to the scaffolding (e.g., graft) using the continuous suture passer, while positioned in the femoral notch.

In one variation, the ACL is sutured to the anchor prior to implanting the anchor in the femoral notch, and the anchor with the end of the femoral notch is then positioned (e.g., by pulling the anchor using a guidewire and or the suture) into position, where it can be expanded or otherwise fixed into position.

FIGS. 3A-3P illustrate one method for repair of an ACL. In this example, the ACL has ruptured proximally within the femoral notch, and the procedure is performed within 3 weeks of the injury. FIG. 3A illustrates a portion of the patient's knee, showing the joint between the femur and the tibia, and in particular illustrating the femoral notch (“notch”). In FIG. 3B the notch is prepared by driving a beath pin into the posterolateral femoral notch, as shown. Alternatively, the region may be drilled or otherwise penetrated to form a narrow passage through femur head from the femoral notch. In this example, the beath pin is driven from within the notch and through the femur head region. Next, as shown in FIG. 2B, the pin is then over-drilled to form a cavity into which the anchor may be seated; the opening faces the notch. In this example, the cavity is drilled with a bit that is approximately one size smaller than the anchor (a screw-type anchor is illustrated here). For example if the outer diameter of the anchor is about 5-6 mm in diameter, the drill bit diameter may be about 4-5 mm. The depth of drilling may be slightly longer than the length of the anchor. For example, in this illustration the depth of drilling is approximately 25 mm, as shown in FIG. 3D.

In some variations, particularly those in which the scaffold (e.g., graft) attached to the distal tip of the anchor is positioned to the side of the anchor (as illustrated in FIG. 1A), a second cavity may be formed adjacent to the anchor cavity to allow room for the graft. This is shown in FIG. 3E. In this example, a dual barrel impacter is driven (e.g., malleted) along the guide wire (beath pin) to create a second, smaller tunnel just superior to the previously drilled hole. This is shown in FIGS. 3F and 3F1. The graft may fit into the adjacent tunnel without substantially weakening the attachment of the anchor.

FIG. 3G illustrates the insertion of the knotless screw over the guide wire/pin into the pre drilled hole within the lateral femoral notch; the graft is inserted into the adjacent channel. The anchor and graft may be pushed or pulled (using the guidewire) into position. For example, a pusher may be used to drive the anchor into the channel drilled in the bone. In some variations the anchor is screwed into the channel, over the guidewire; for example an applicator may removably couple with the proximal end of the anchor and allow it to be inserted into the femur by pushing and/or screwing, particularly in the threaded screw-type anchors. The graft, which is coupled to the distal end of the anchor, may stay in the adjacent channel as the anchor is inserted; the coupling region for the scaffold/graft is rotatable relative to the rest of the anchor, thus as the anchor is rotated to insert, the graft may stay in the channel. As shown in FIG. 3H, the reinforcement graft sits snuggly within the pre-punched tunnel just superior to the anchor, allowing optimal in-growth of the graft into the femoral bone.

Once the anchor is secured in the femoral arch with the graft extending from the arch, the end region of the ACL may be pulled into position using a suture. Prior to this step the ACL may be secured with a suture as shown in FIGS. 4A-4D. In FIG. 4A, the ACL is sutured to securely attach the end of the ACL to a doubled-back suture. In this example a continuous suture passer may be used to pass the midpoint of a free suture around and then through the ACL stump, as shown in FIG. 4A. In FIG. 4B, the suture is then fed through the loop to secure the tissue in a self cinching manner, as shown in FIG. 4C. In some variations, this can be done outside of the knee, without tissue interference, because the suture has been inserted into the knee, passed through the ACL tissue, and removed all through the same single pathway. Finally as shown in FIG. 4D, the ligament is now secured and the sutures are ready to be loaded into the knotless anchor.

Returning now to FIG. 3I, the suture ends from the previously sewn ACL may then be fed into the eyelet of the beath pin (which may be done outside of the knee), and the beath pin drawn through the anchor (e.g., pulling distally and/or pushing proximally) to draw the ACL to the proximal end of the anchor and adjacent to the graft, as shown in FIG. 3J. For example, the beath pin may then be pulled out from the lateral knee as is typically done with current ACL reconstruction techniques, and the suture follows and is therefore loaded into the anchor. In FIG. 3K, both ends of the suture have been withdrawn through the anchor distally by pulling on beath pin (guidewire) as illustrated. Because the suture channel through the guidewire does not allow the suture(s) to be withdrawn proximally, either or both ends of the suture may be pulled distally to draw the end of the ACL near the proximal end of the anchor within the bone, and adjacent to the graft.

The ligament can be tensioned by pulling on the sutures with the desired amount of force. This may reduce the knee (e.g., pulling the tibia back into position relative to the femur) and may bring the ACL tissue back to its origin on the femoral notch. Thereafter the proximal end of the suture may be knotted and cut, as shown in FIG. 3M. For example, a small (e.g., 2 mm) incision can be made where the sutures exit the skin and any standard arthroscopic knot cutter can be slid down to the lateral femur where the sutures can then be safely cut flush with the bone.

Finally, the ACL can be sutured to the graft/support material, as shown in FIGS. 3N to 3P. In this example, the continuous suture passer is brought in to sew the graft to the ACL to reinforce the repair. The continuous suture passers described herein may be positioned within the notch and still function to pass a suture through the ACL and the graft material, within the limited space of the notch. The final repair allows for a well-tensioned, significantly reinforced ACL repair.

In some variations, platelet-rich plasma or other biologic healing stimulants may also be added following or during the procedure in the notch. Note that FIGS. 3A-3P are not drawn to scale. For illustrative purposes, the screw anchor shown in the figures appears larger than the ligament in the drawings; in actuality the ligament is likely to be considerably larger that the screw.

Although the foregoing invention has been described in some detail by way of illustration and example for purposes of clarity of understanding, it is readily apparent to those of ordinary skill in the art in light of the teachings of this invention that certain changes and modifications may be made thereto without departing from the spirit or scope of the appended claims. 

What is claimed is:
 1. A method for repairing a torn ACL within the femoral notch, the method comprising: anchoring a graft within the femoral notch; securing a torn end of the ACL to a suture and pulling the suture through the femur to position the torn end of the ACL adjacent to the graft; and suturing the torn end of the ACL to the graft within the femoral notch.
 2. The method of claim 1, wherein anchoring a graft comprises securing an anchor to which a graft has been coupled within the femur so that a proximal end of the graft extends from the femur.
 3. The method of claim 1, wherein anchoring a graft comprises driving a guidewire through the femur and drilling an opening to hold a graft anchor; and securing an anchor coupled to a graft within the opening over the guidewire.
 4. The method of claim 3, wherein the anchor is secured by screwing the anchor into the opening.
 5. The method of claim 1, wherein suturing the torn end of the ACL comprises passing a suture through the graft and the ACL multiple times.
 6. The method of claim 1, wherein suturing the torn end of the ACL comprises passing a suture through the graft and the ACL multiple times with a continuous suture passer without removing the suture passer from the tissue.
 7. The method of claim 1, further comprising securing the torn end of the ACL to a suture and pulling the suture through the femur to anatomically tension the ACL adjacent to the graft.
 8. A method for repairing a torn ACL within the femoral notch, the method comprising: anchoring a graft within the femoral notch; positioning a torn end of the ACL adjacent to the graft; wherein positioning comprises securing a suture to the torn end of the ACL; pulling the suture through a tunnel in the femoral notch to position the torn end of the ACL adjacent to the graft; and percutaneously suturing the torn end of the ACL to the graft within the femoral notch.
 9. The method of claim 8, further comprising anchoring the torn end of the ACL to the femoral notch with a suture before percutaneously suturing the torn end of the ACL to the graft.
 10. The method of claim 8, further comprising drilling a tunnel through the femoral arch for anchoring the torn ACL.
 11. The method of claim 8, wherein anchoring the graft within the femoral notch comprises anchoring the graft within a tunnel drilled through the femoral arch.
 12. A method for repairing a torn ACL within the femoral notch, the method comprising: drilling a tunnel through a portion of the femoral notch; anchoring a graft within the tunnel through the femoral notch, wherein the graft extends from the tunnel; pulling a suture connected to a torn end of the ACL through the tunnel through the femoral arch to position the torn end of the ACL adjacent to the graft; anchoring the suture connected to the torn end of the ACL; and percutaneously suturing the torn end of the ACL to the graft within the femoral notch. 